Only skin deep?

Most patients feel that the management of their disease impacts on their daily lives

Eczema is widely regarded as a relatively minor skin condition, but the truth is that severe eczema can have a devastating effect on a sufferer’s quality of life

Skin conditions are sometimes deemed as superficial, minor and cosmetic. But a new patient survey by charity Allergy UK – part of a wider report in partnership with Sanofi Genzyme, entitled Seeing Red: Getting Under the Skin of Eczema – found that most (88 per cent) patients feel that the management of their disease impacts on their daily lives, more than half (58 per cent) say it affects their personal relationships and over 70 per cent feel depressed as a result of the disease.

People with severe eczema described how they suffer from depression, lack of self-esteem, exhaustion, embarrassment and anxiety. These feelings make many of the usual day-to-day aspects of life, such as holding down a job or going out on social occasions, difficult and sometimes even impossible.

“I’m constantly physically and mentally exhausted. I have blood and skin in my bed every morning, skin coming off in my clothing, and have to cover myself in emollients etc…my children don’t want to be near me when I’m sticky,” says one patient.

Another says: “It’s horrible because it weeps so everything you touch leaves a mark and people shy away from touching you like you will contaminate them too.”

While another patient describes their condition as a “living hell” which has hampered their academic and career progress.

Despite these challenges for patients, the report highlights that “this distressing and painful condition has been significantly under-prioritised by policy makers and the NHS. Patients are suffering because there are no national guidelines or quality standards, healthcare professionals lack knowledge of skin conditions in primary care and there are lengthy waiting times to see a dermatologist”.

These shortcomings mean that many patients are likely to seek advice and support from the pharmacy as their first port of call, says Dr Anton Alexandroff, consultant dermatologist and spokesman for the British Association of Dermatologists and the British Skin Foundation.

He says: “The pharmacy team is ideally placed to guide patients to practical solutions which can improve the quality of their lives. Staff should have a general overview of the treatment options available and know when a patient should be referred to the pharmacist, GP or dermatologist. They need to have empathy and an understanding of the impact this disease can have on people, good communication skills and be aware of the need to avoid medical jargon when talking to customers.”

What is severe eczema?

Severe eczema, also known as atopic dermatitis and atopic eczema, is a chronic inflammatory autoimmune disease, which can cause the skin barrier to break down. This can increase a person’s susceptibility to triggers, such as dust, pollen, soaps, detergents, stress and the weather.

While some people outgrow the disease, a number of adults continue to experience symptoms for life – it is estimated that 1.5 million adults in the UK have atopic dermatitis, many of whom have a more chronic and severe form. It tends to run in families and a genetic disposition to allergy can increase the likelihood of eczema being severe.

The main symptom of severe eczema is extreme and persistent itching. The skin becomes red, dry, cracked and sore from scratching. If the scratching breaks the skin, infections can set in which can cause even more discomfort.

People typically experience cycles of flare-ups and remission. Flare-ups are fuelled by a breakdown in the immune system, which can cause changes in the upper layer of the skin including redness, blistering, oozing, crusting, scaling, thickening and pigmentation.

Treatment options

Skin conditions can have a severe impact on people’s mental and physical wellbeing

Keeping the skin moisturised on a daily basis using emollients is the mainstay of treatment for all types of eczema, with topical steroids commonly used to reduce swelling, redness and itching during flare-ups. A GP or dermatologist can prescribe other treatments in severe cases.

Avoiding triggers, controlling the scratching if possible and making any necessary dietary changes can also help sufferers.

Amena Warner, head of clinical services, Allergy UK, says pharmacy teams need to have a basic understanding of the different types of emollients so that they can discuss the difference between a lotion, cream or ointment and which should be recommended for dry, moderately dry or just slightly dry skin.

“You also need to find out what works best for people’s lifestyles. Find out whether they need to carry their treatment around with them to apply during the day, so they will need a large tub to keep at home in the bathroom and a smaller travel version they can keep in their bag during the day.”

Dr Alexandroff says regular application of a moisturiser and washing with a moisturiser, also known as a soap substitute, instead of soap is key. “When it comes to advising patients on moisturisers it’s important to bear in mind that some people can tolerate greasier creams than others. Although a greasier cream is usually better, if the patient won’t put it on because they hate the way it feels then it is no use at all. It’s also worth pointing out to people that more expensive creams certainly don’t mean that they are more effective.”

He also reminds counter staff that aqueous cream, originally developed as a soap substitute, is often used as a moisturiser but can irritate the skin and make eczema worse. For this reason it is recommended that aqueous cream is not used as a moisturiser.

Dr Alexandroff adds that pharmacy teams are also well placed to warn patients off buying so-called “natural” herbal creams, as they can cause irritation and allergic reactions. Some of these creams have been shown to contain potent steroids. Other herbal creams have been shown to contain high levels of harmful bacteria including MRSA which may cause skin infections and septicaemia.

Karen Braithwaite, pharmacist of Aberlour Pharmacy, Moray, who has a special interest in eczema, says it is also important to listen carefully to patients’ concerns: “Everyone is so different. Some people are self-confident on the inside and their eczema doesn’t define them. We have to be careful not to make a drama out of their condition if they are perfectly well-adjusted with it. So first ask an open question such as – how do you feel about your skin? Then listen to how the customer describes their symptoms and how they talk about what bothers them. It may be the itch, lack of sleep or that they worry that their skin is not pleasant to look at.

“This is a condition that we see a lot in prescriptions, minor ailments and over the counter, so it’s important that we can give customers both practical advice and emotional support. It’s an area where we can really connect with customers and build their loyalty to the pharmacy.

Skin conditions explained

Cold sores

Cold sores are small, painful, blisters that develop on the lips or around the mouth. They usually start with a tingling, itching or burning feeling. They are caused by the herpes simplex virus and usually clear up without treatment within seven to 10 days. Most people are exposed to the virus when they are young and then it lives in the skin and may be triggered by another illness, stress, sunshine or menstruation. Cold sores are highly contagious.

OTC creams can ease pain and irritation; antiviral creams can speed up healing time and cold sore patches can protect the skin while it heals. Self care includes eating cool, soft foods, using an antiseptic mouthwash if it hurts to brush the teeth, wash hands before applying cream and use sunblock lip balm.

Rosacea

Rosacea is found on the central part of the face, usually of a middle-aged person. Symptoms include episodes of flushing, burning and stinging sensations, permanent redness, small inflamed red bumps and pus spots and small blood vessels visible in the skin. Rosacea is a common relapsing condition more common in women than in men, and in those with a fair skin who flush easily. Trigger factors include alcohol, exercise, high and low temperatures, hot drinks, spicy foods, stress and sunlight. For most people, treatment involves a combination of self care measures such as avoiding known triggers, using sunblock and using an emollient to clean the face if the skin is dry or sensitive, plus medication prescribed by a GP.

Acne

Acne causes blackheads, whiteheads, spots and pus-filled pustules. It usually starts at puberty when hormones cause the greaseproducing glands next to hair follicles in the skin to produce more oil, which gets trapped in the hair follicles along with skin cells, causing a blockage. Advice includes: don’t squeeze spots, as this can make them worse and cause scarring; wash the affected area with a mild soap or cleanser and lukewarm water, no more than twice a day; and use water-based products that are less likely to block the pores in the skin. People with mild acne can treat the condition with OTC gels or creams that contain benzoyl peroxide or nicotinamide. People with severe acne should be referred to a GP.

Psoriasis

Psoriasis causes red, flaky, crusty patches of skin covered with silvery scales. People with psoriasis have an increased production of skin cells, which are replaced every three to four days instead of the usual 21-28 days. Psoriasis patches can be itchy or sore. Inherited and environmental factors play a role in the development of the condition. Factors such as infections, certain medicines, stress, alcohol and/or smoking can trigger flare-ups. The condition can be kept under control with emollients, creams, ointments, gels, pastes and lotions. More severe symptoms can be treated with phototherapy and oral or injected medications, prescribed by the GP. A healthy lifestyle also helps.

Most patients feel that the management of their disease impacts on their daily lives

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